• Implementation of Dextrose gel for Asymptomatic Hypoglycemia in Newborns

      Solaiman, Anjana; Wise, Barbara V. (2020-05)
      Problem & Purpose: Neonatal asymptomatic hypoglycemia is a common problem that may contribute to poor health outcomes. Firstline treatment includes formula feeding, and/or transfer to the Neonatal Intensive Care Unit (NICU) for intravenous glucose. Both of these treatment options are sub-optimal because breastfeeding/bonding are disrupted, and costs may be increased due to NICU care. The purpose of this quality improvement (QI) project was to implement 40% buccal dextrose gel as the first line treatment of asymptomatic hypoglycemia in newborns at an academic medical center in the mid-Atlantic region to improve glycemic outcomes. Methods: This QI project was implemented during a 12-week period in the Fall of 2019. The target population included infants admitted to the newborn nursery who were less than 24 hours of life (HOL) with an identified risk factor for hypoglycemia (birthweight >3800 grams or <2500 grams, gestational age <37 weeks, LGA or SGA, or is an infant of diabetic mother), with asymptomatic hypoglycemia (blood glucose levels between 20- 40mg/dl). The QI project involved modifying the hospitals current neonatal hypoglycemia clinical practice guideline (CPG), to implement 40% dextrose gel as initial therapy in conjunction with feeding, developing an order set, creating documentation in the electronic health record, training personnel and collaborating with pharmacy to stock the gel. Results and Conclusions: During the implementation 16 newborns received glucose gel (N=16). Treatment success, defined as blood glucose levels >40mg/dL following the first and/or second administration of gel, was achieved in 87.5% of newborns. Newborns who did not respond favorably to glucose gel had an initial blood glucose level of <20mg/dL, a deviation from the modified CPG. Fifty five percent of newborns who were exclusively breastfeeding (N=9) received medically indicated formula supplementation. Five patients were transferred (N=5) to the NICU, 2 patients had achieved treatment success, but were unable to maintain adequate glycemic levels. Future QI cycles should include exploration of treatment failure with modifications to improve CPG adherence, consideration for increasing doses for responsive newborns as well widening the gestational age criteria. Overall the outcomes of this QI project demonstrated that glucose gel as the initial treatment for infants with asymptomatic hypoglycemia is effective.
    • A Neonatal Dextrose Gel Algorithm to Increase Exclusive Breastfeeding Rates at Discharge

      Indenbaum-Bates, Keisha N.S.; Satyshur, Rosemarie D. (2022-05)
      Problem & Purpose: Over 80% of newborns nationally are breastfed after birth, yet the exclusive breastfeeding rate of a Women’s Health Services Department was 8%. Formula supplementation of hypoglycemic breastfed babies was identified as a contributing factor to this problem. Evidence demonstrates that using oral dextrose gel to treat neonatal hypoglycemia is safe, efficacious, and can increase breastfeeding rates. The purpose of this project was to implement an oral dextrose gel algorithm for the management of neonatal hypoglycemia to increase exclusive breastfeeding rates at discharge. Goals were to educate 100% of staff nurses on the practice change, administer the gel to 100% of eligible newborns, establish euglycemia in 100% of eligible newborns, and increase exclusive breastfeeding rates at discharge. Methods: A quality improvement project was designed to implement a neonatal dextrose gel algorithm over a 21-week period on a 26-bed mother-baby unit by a team of key stakeholders. In-services and hands-on validations were used to educate staff and the practice change was integrated into the electronic health record system and department policies prior to implementation. The implementation team met weekly to discuss progress and barriers, change champions were used to increase uptake, visual reminders of the algorithm were placed in key areas, and staff huddles were used for continuing education. Results: 95.8% of staff nurses were educated and validated on the practice change, average adherence to the algorithm was 47.2%, and the exclusive breastfeeding rate of newborns at risk for hypoglycemia increased from 17.7% to 18.7% (p=0.9). No babies became hypoglycemic during the implementation phase. Conclusions: Implementing a neonatal dextrose gel algorithm on a mother-baby unit is feasible and can help promote exclusive breastfeeding. Integration into formal unit policies and both new-hire and annual staff competencies is key to sustainability.
    • Prevention of Newborn Hypoglycemia Algorithm

      Parajon, Cecilia M.; Hoffman, Ann G. (2019-05)
      Background: Newborns at a higher risk for developing hypoglycemia are defined as newborns born small or large for gestational age, late-preterm (34-36 and 6/7 weeks gestation), those born to mothers with diabetes and any newborn exhibiting clinical signs of hypoglycemia. Identified newborns are monitored and often fed formula to stabilize their blood glucose level. Many mothers plan to breastfeed exclusively, but when formula is fed to their newborns exclusive and long-term breastfeeding is decreased. Applying the Baby-Friendly Hospital Initiative interventions like skin to skin care, frequent breastfeeding and feeding hand expressed colostrum to the at-risk newborns may prevent hypoglycemia, stabilize the glucose levels, lessen formula supplementation, and increase exclusive breastfeeding rate. The Prevention of Newborn Hypoglycemia Algorithm supports the AAP Screening and Management of Postnatal Glucose Homeostasis Algorithm, the Academy of Breastfeeding Medicine and the Baby Friendly guidelines to prevent and reduce newborn hypoglycemia and related formula use, increase breastfeeding rates and thereby improve delivery of care. Local Problem: The community hospital was initiating the process of becoming a Baby Friendly Hospital and recognized that their use of formula to manage hypoglycemia in at-risk newborns was very high and sought to decrease its use and consequently increase breastfeeding rates. The hospital currently uses an algorithm based on the AAP Hypoglycemia Algorithm that does not incorporate some of the Baby Friendly interventions. There are inconsistencies of the management in the care of the at-risk newborns. Interventions: The purpose of this quality improvement project was to implement and evaluate the effectiveness of the Prevention of Hypoglycemia Algorithm for the at-risk newborns in a community hospital. The implementation included instruction and guidance of the nursing staff in the components and the use of the algorithm. The use of the algorithm was assessed in the overall and the at-risk number of newborns that were ever and exclusively breastfed during the intervention period. At the end of the implementation, the nurses evaluated the usability of the algorithm with the Algorithm Usability Questionnaire. Results: Overall the ever-breastfeeding rate increased slightly but the exclusive breastfeeding rate dropped. During the intervention, all of the at-risk newborns were managed with parts of the algorithm and 100% breastfed some of the feedings. The exclusively breastfeeding rate was 67% in the first month and 20% the second month. There was a 70% staff approval for ease of use of the algorithm. Conclusions: All at-risk newborns breastfed for some of the feedings in the hospital during the intervention. There was an increase in the awareness of at-risk newborn hypoglycemia prevention and the use of the algorithm recommendations for all newborns. The algorithm served as a prompt to apply the Baby Friendly interventions while preventing hypoglycemia, managing the blood glucose levels, lessen formula supplementation and preserving the newborns breastfeeding abilities. The Algorithm remained posted on the nursing unit to assist this practice change to manage the at-risk newborns and help the hospital become a Baby-Friendly designated facility.